1 Cancer care

Overview/pathophysiology

The term cancer refers to several disease entities, all of which have in common the proliferation of abnormal cells. To varying degrees, these cells have lost their ability to reproduce in an organized fashion, function normally, and die a natural death (apoptosis). As a result they may develop new functions not characteristic of their site of origin, spread and invade uncontrollably (metastasize), and cause dysfunction and death of other cells.

Cancer is the second leading cause of death in the United States after cardiac disease, accounting for nearly 1 of every 4 deaths (American Cancer Society, 2009d). It can cause damage and dysfunction at the site of origin or regionally, or metastasize and cause problems at more distant body sites. Eventually a malignancy may cause irreversible systemic damage and failure, resulting in death. While the exact cause of many cancers remains unclear, cancers caused by cigarette smoking and heavy alcohol use could be prevented completely. The American Cancer Society (ACS) (American Cancer Society, 2009d) estimated that one-third of cancer deaths for 2009 are related to overweight or obesity, physical inactivity, and poor nutrition and could also be prevented. Other cancers related to infectious agents could be prevented through behavioral changes, vaccines, or antibiotics. Similarly, many skin cancers could be prevented by protection from the sun’s rays and avoiding indoor tanning. Regular screening is important for early detection of screenable cancers (breast, colon, rectum, cervix, prostate, oral cavity, skin). The number of adults surviving and living with cancer has increased and is estimated to be over 11 million (Horner et al., 2006).

Health care setting

Medical or surgical floor in acute care; primary care, hospice, home care, long-term care

Care of patients with cancer

See also: “Perioperative Care,” p. 42; “Fecal Diversions,” p. 419; and “Managing Wound Care,” p. 515, for appropriate nursing diagnoses, outcomes, and interventions.

Neoplastic diseases of the hematopoietic system

Hematopoietic system cancers include lymphomas, leukemias, plasma cell disorders, and myeloproliferative disorders.

Depending on cellular type, lymphomas are classified as Hodgkin and non-Hodgkin and are characterized by abnormal proliferation of lymphocytes. In addition to characteristic lymph node enlargement, involvement of other lymphoid organs such as the liver, spleen, and bone marrow does occur. Treatment planning, based on disease stage, usually involves chemotherapy and sometimes radiation therapy for eradication of local disease. Patients with Hodgkin lymphoma may have a chance for cure, whereas patients with certain grades of non-Hodgkin lymphoma may face treatment decisions for the remainder of their lives.

Screening:

Currently there is no routine screening recommended for the lymphomas.

Leukemia is the abnormal proliferation and accumulation of white blood cells (WBCs). Divided into two categories, leukemia presents as either acute or chronic, depending on cellular characteristics. Acute leukemia, characterized by abnormal proliferation of immature WBCs, also known as precursor or progenitor cells, is classified by the type of WBC involved. Treatment consists predominantly of chemotherapy and biologic therapy, with radiation therapy for CNS prophylaxis when indicated.

Chronic leukemia, characterized by abnormal proliferation of mature differentiated WBCs, is typically treated with chemotherapy; some forms of chronic leukemia may remain indolent for years, delaying treatment indefinitely. In both types of leukemia, abnormal cells may interfere with normal production of other WBCs, red blood cells (RBCs), and platelets. Patients with chronic lymphocytic leukemia may have compromised immunity, resulting in frequent and possibly fatal infections.

Screening:

No screening recommendations currently exist for leukemia. Diagnosis usually occurs when the presenting symptoms include fever, malaise, bruising or bleeding, infections, adenopathy, hepatosplenomegaly, weight loss, or night sweats but may also be initially noted on routine complete blood count (CBC). Diagnosis is confirmed with a CBC and peripheral smear and by bone marrow biopsy.

See also: “Hematologic Care Plans,” p. 455, for appropriate nursing diagnoses, outcomes, and interventions related to care of patients with abnormal blood cells.

Head and neck cancers

Head and neck cancers include tumors of the tonsils, larynx, pharynx, tongue, and oral cavity. Incidence is greatest in men older than age 50, and incidence rates are double in men compared to women. By far the greatest risk factors are tobacco consumption through smoking or smokeless tobacco and alcohol consumption.

Screening:

Although no formal recommendations regarding screening exist, routine dental examinations are one mechanism by which early detection occurs.

See also: “Pneumonia,” p. 117, for outcomes and interventions in Ineffective Airway Clearance.

Breast cancer

The National Cancer Institute estimates that approximately 2.5 million women with a history of breast cancer were alive in 2006 (Horner et al., 2006). Despite higher incidence rates among Caucasian women, breast cancer death rates are higher among African American women (American Cancer Society, 2009b). Taking into account tumor size, stage, and other characteristics as well as patient preference, treatment may include lumpectomy, mastectomy, and removal of some axillary lymph nodes. Radiation therapy, chemotherapy, hormone therapy, or targeted biologic therapy may also be a part of treatment (American Cancer Society, 2009b). The 5-year relative survival for female breast cancer has improved from 63% in the 1960s to approximately 89%. The survival rate for women diagnosed with localized breast cancer (has not spread to lymph nodes or other locations outside the breast), approaches 98%.

Screening:

At the time of this writing, recommendations for breast cancer screening are being reviewed by various agencies and there may be differences in recommendations among groups. For example, in 2009, the United States Preventive Services Task Force (USPSTF) revised its recommendations. The USPSTF recommends biennial screening mammography for women aged 50 to 74 years, does not recommend breast self-examination, and does not have evidence to support the benefits and harms of screening after age 75 (U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, 2009). The American Cancer Society (American Cancer Society, 2009b) recommends a screening mammogram every year for women beginning at age 40 and for as long as they remain in good health. Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, at least every 3 years. After age 40, women should have a clinical exam by a health expert every year. Breast self-exam (BSE) remains an option for women beginning in their 20s, although not routinely recommended by the American Cancer Society. Women should be told about the benefits and limitations of BSE. Women at higher risk for developing breast cancer may need to begin mammography before age 40.

See also: “Perioperative Care,” p. 42, for appropriate nursing diagnoses, outcomes, and interventions; and Risk for Disuse Syndrome, p. 12, in this section.

Genitourinary cancers

For both men and women, genitourinary cancers include cancers of the bladder, kidney (renal cell), renal pelvis, ureter, and urethra and Wilms tumor and other childhood kidney tumors. Additional sites for men include the penis, prostate, and testicle. Sites of neoplasms of the female pelvis include the vulva, vagina, cervix, uterus, and ovaries. Selected cancers are briefly summarized in the following.

Bladder cancer is classified as superficial or invasive. Treatment is chosen based on extent of disease and may include surgery, local or systemic chemotherapy, laser surgery, or radiation. Metastases occur commonly in bone, liver, and lungs. Bladder cancer incidence is higher in men than in women.

Screening:

No standards currently exist for screening for bladder cancer; however, survival may depend on prompt evaluation of early symptoms.

Prostate cancer occurs most commonly in men older than age 50. Over 60% of all prostate cancer cases are diagnosed in men aged 65 and older. African American men and Jamaican men of African descent have the highest prostate cancer incidence in the world (American Cancer Society, 2009c). Treatment may consist of a combination of interstitial or external radiation therapy, chemotherapy, surgery, or hormonal therapy. Choice of treatment is determined in part by the disease stage and cellular histology at diagnosis and by clinician preference. In general, prostate cancers tend to grow slowly and metastasize late, enabling patients to live several years with the disease while maintaining an acceptable quality of life.

Screening:

It is recommended that a man discuss the benefits and limitations of prostate cancer screening and make an informed decision as to whether or not he should be screened. (American Cancer Society, 2009d; United States Preventive Services Task Force, 2008) For men who choose to be screened, the American Cancer Society recommends that health care providers offer the prostate-specific antigen (PSA) blood test and the digital rectal examination (DRE) yearly, beginning at age 50, to men at average risk who do not have any major medical problems and can be expected to live at least 10 more years. Men at high risk should begin testing at age 45. Men at high risk include African Americans and those who have a close relative (father, brother, or son) who had prostate cancer before age 65. When a biopsy of the prostate gland is performed to diagnosis prostate cancer, a Gleason score is determined when the biopsy is looked at under the microscope. The Gleason score is used along with the PSA and DRE results to determine staging. This score (range 2-10) indicates how likely the cancer is to spread. The lower the score, the less likely it is that the cancer will spread (National Cancer Institute, 2010).

Testicular cancer occurs most often in men between ages 20 and 40. Tumors are classified as seminomas and nonseminomas, depending on their cellular line of differentiation, with many consisting of a mixed cellular type. Nonseminomas tend to grow and metastasize more aggressively. Treatment nearly always begins with surgery and, depending on histology, blood tumor markers, and bulk of disease, may be followed by chemotherapy and/or radiation therapy. Surgical correction for cryptorchidism is recommended before age 6 to significantly reduce the risk of later development of testicular cancer.

Screening:

Screening programs are not routinely conducted, but a routine physical examination should include examination of the testes, which would detect an undescended testicle or mass. Any scrotal mass should be evaluated promptly.

Renal cell carcinomas, most predominantly classified as adenocarcinomas with histologic variants, occur in about 2% of all malignant diagnoses. Surgery is nearly always the treatment of choice for early stage renal cell cancers, and radiation therapy for control of symptoms is usually indicated for more advanced disease. Chemotherapy has a limited role with management of renal cell cancer. Biologic response modifiers are an option for more advanced disease. Incidence of renal cancer is higher in men than in women.

Screening:

No routine screening method exists to detect renal cell cancer, and incidence likely would be lowered if predominance of cigarette smoking could be reduced. Reports of hematuria should be investigated thoroughly. Presentation of any other symptoms compatible with renal cell carcinoma may forebode disease that is more advanced.

See also: “Perioperative Care,” p. 42; “Urinary Diversions,” p. 225; and “Benign Prostatic Hypertrophy,” p. 194, for appropriate nursing diagnoses, outcomes, and interventions. Also see Stress Urinary Incontinence, p. 10; and Sexual Dysfunction, p. 11, in this section.

Cervical cancer incidence has decreased over the past several decades. The primary cause of cervical cancer is infection with certain types of human papillomavirus (HPV). Women who begin having sex at an early age or who have many sexual partners are at increased risk for HPV infection and cervical cancer. The Food and Drug Administration (FDA) has approved the first vaccine developed to prevent the most common HPV infections that cause cervical cancer, for use in females aged 9 to 26 years (American Cancer Society, 2009d). The increased use of the Papanicolaou (Pap) smear as a screening tool for cervical cancer has resulted in more frequent detection of preinvasive carcinoma in situ (CIS). Treated early, usually with surgery and sometimes with radiation therapy, cervical cancer is a curable disease. Surgery, chemotherapy, and/or radiation may manage stages that are more advanced.

Ovarian tumors occasionally detected during an annual pelvic examination are more commonly occult until symptoms of advanced disease are present. Treatment is initially surgical, which is a vital step for proper tumor staging. Survival, directly related to proper treatment, can only be determined by proper staging. Chemotherapy is commonly given after surgery.

Endometrial cancer, usually treated with surgery, is followed by radiation therapy in all but the earliest stages. Chemotherapy and hormonal therapy are usually reserved for advanced stages in which a surgical cure is not feasible and invasion of local or more distant tissues has occurred.

Screening:

The American Cancer Society (American Cancer Society, 2009a) recommends an annual Pap smear and pelvic examination for women 3 years after beginning vaginal intercourse or by age 21. If using a liquid-based Pap test, women should be screened every 2 years. If using conventional Pap tests, screening should be done annually. At or after age 30, women who have had three normal consecutive annual examinations may elect to have screening every 2 or 3 years as recommended by their health care provider. Women age 70 or older who have had three consecutive normal Pap tests and no abnormal tests in the past 10 years may elect to discontinue annual Pap tests. Likewise, women with a total hysterectomy, including removal of the cervix, may elect no further Pap tests.

Endometrial biopsy remains the definitive standard to assess for endometrial cancer. For women with or at high risk for hereditary non-polyposis colon cancer (HNPCC), annual screening should be offered for endometrial cancer with endometrial biopsy beginning at age 35. However, there is no routine screening recommendation for endometrial cancer.

See also: “Perioperative Care,” p. 42, for appropriate nursing diagnoses, outcomes, and interventions.

Nursing diagnoses and interventions for general cancer care

Note:

The following nursing diagnoses, desired outcomes, and interventions relate to generalized cancer care. Those for care specific to chemotherapy, immunotherapy, and radiation therapy follow this section.

Nursing diagnosis:

Ineffective breathing pattern

Note:

For desired outcome and interventions, see this nursing diagnosis in “Perioperative Care,”p. 46.Some chemotherapeutic agents (bleomycin, carmustine, busulfan, cytarabine, mitomycin, cyclophosphamide, methotrexate, melphalan, interferon alfa-2b, interleukin-2, fludarabine) can cause pulmonary toxicity, an inflammatory reaction that results in fibrotic lung changes, cellular damage, and decreased lung capacity. Radiation therapy can also cause pulmonary damage and changes resulting in decreased lung capacity.

Nursing diagnosis:

Acute pain

Note:

For desired outcome and interventions, see “Pain,” p. 37.

Nursing diagnosis:

Chronic pain

Desired Outcome: Patient participates in a prescribed pain regimen and reports that pain and side effects associated with the prescribed therapy are reduced to level of three or less within 1-2 hr of intervention, based on pain assessment tool (e.g., descriptive, numeric [on a scale of 0-10], or visual scale).

ASSESSMENT/INTERVENTIONS	RATIONALES
After patient has undergone a complete medical evaluation for the causes of pain and the most effective strategies for pain relief, assess patient’s understanding of the evaluation and pain-relief strategies.	This review helps determine patient’s level of understanding and reinforces findings, thereby promoting patient’s knowledge and adherence to pain relief strategies. It also empowers patient as much as possible to participate in controlling his or her pain.
Assess patient’s cultural beliefs and attitudes about pain. Never ignore a patient’s report of pain, taking into consideration that a patient’s definition of pain may be different from that of the assessing nurse. Promptly report any change in pain pattern or new complaints of pain to health care provider.	Cultural beliefs may influence how individuals describe their pain and its severity and their willingness to ask for pain medications. Pain is dynamic, and competent management requires frequent assessment at scheduled intervals.
Assess patient’s level of “discomfort” or abnormal sensations in addition to the usual pain queries.	Patients with neuropathic pain may not describe their discomfort as pain; therefore, be sure to use additional terms. Nociceptive pain refers to the body’s perception of pain and its corresponding response. It begins when tissue is threatened or damaged by mechanical or thermal stimuli that activate the peripheral endings of sensory neurons known as nociceptors. In contrast, neuropathic pain is caused by damage to central or peripheral nervous system tissue or from altered processing of pain in the CNS. The resulting pain is chronic, may be difficult to manage, and is often described differently (burning, electric, tingling, numbness, pricking, shooting) from nociceptive pain.
Include the following in your pain assessments:
– Characteristics (e.g., “burning” or “shooting” often describes nerve pain). – Location and sites of radiation.	Not all types of pain are managed solely by opioid therapy. Characterizing pain and documenting its location accurately will result in better pharmacologic intervention and assist nurses in developing a customized plan that incorporates nonpharmacologic measures as well.
– Onset and duration.	Determining precipitating factors (as with onset) may assist in preventing or alleviating pain.
– Severity: Use a pain scale that is comfortable for patient (e.g., descriptive, numeric, or visual scale).	Severe pain can signal complications such as internal bleeding or leaking of visceral contents. Using a pain scale provides an objective measurement that enables the health care team to assess effectiveness of pain management strategies. Optimally, patient’s rated pain on a 0-10 scale is 4 or less.
– Aggravating and relieving factors.	This information may assist in preventing or alleviating pain.
– Previous use of strategies that have worked to relieve pain.	Strategies that have worked in the past may work for current pain.
Assess patient’s and caregiver’s attitudes and knowledge about the pain medication regimen.	Many patients and their families have fears related to patient’s ultimate addiction to opioids. It is important to dispel any misperceptions about opioid-induced addiction when chronic pain therapy is necessary. Fears of addiction may result in ineffective pain management.
Incorporate the following principles:
– Administer nonopioid and opioid analgesics in correct dose, at correct frequency, and via correct route.	Pharmacologic management of pain is often the mainstay of treatment of chronic cancer pain. Chronic cancer analgesia is often administered orally. If pain is present most of the day, analgesia should be given around the clock (at scheduled intervals) rather than as needed because prolonged stimulation of the pain receptors increases the amount of drug required to relieve pain.
– Recognize and report/treat side effects of opioid analgesia early.	Side effects include respiratory depression, nausea and vomiting, constipation, sedation, and itching. The presence of these side effects does not necessarily preclude continued use of the drug.
– Use prescribed adjuvant medications.	Adjuvant medications (see p. 38) help increase efficacy of opioids and may minimize their objectionable side effects as well.
– Assess for signs and symptoms of tolerance, and when it occurs discuss treatment with health care provider.	Patients with chronic pain often require increasing doses of opioids to relieve their pain (tolerance). Respiratory depression occurs rarely in these individuals.
– Never stop opioids abruptly in patients who have been taking them for a prolonged period.	There is potential for physical dependence in patients taking opioids for a prolonged period; therefore, they should be tapered gradually to prevent withdrawal discomfort.
– Use nonpharmacologic approaches, such as acupressure, biofeedback, relaxation therapy, application of heat or cold, and massage when appropriate. See “Pain,” p. 41, for details.	Nonpharmacologic approaches are often effective in enhancing effects of opioid therapy.

Nursing diagnosis:

Ineffective peripheral tissue perfusion

Desired Outcome: Following intervention/treatment, patient exhibits adequate peripheral perfusion as evidenced by peripheral pulses greater than 2 on a 0-4 scale, normal skin color, decreasing or stable circumference of edematous site, equal sensation bilaterally, and ability to perform range of motion (ROM) in the involved extremity.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess involved extremity for degree of edema, quality of peripheral pulses, color, circumference, sensation, and ROM.	This assessment helps determine presence/degree of lymphedema and potential threat to limb from hypoxia. Patients may be at risk based on a variety of disease processes, treatments, and medications.
Assess for tenderness, erythema, and warmth at edematous site.	These signs of infection need to be communicated to the health care provider for prompt intervention. A continuous supply of oxygen to the tissues through microcirculation is vital to the healing process and for resistance to infection.
Elevate and position involved extremity on a pillow in slight abduction. If surgery has been performed, instruct patient not to perform heavy activity with the affected limb during recovery period.	As blood collects, waiting to get into the heart, pressure in the veins increases. The veins are permeable, and the increased pressure causes fluid to leak out of the veins and into the tissue. Elevating the extremity helps reduce venous pressure.
Encourage patient to wear loose-fitting clothing.	Tight-fitting clothing may cause areas of constriction, reducing lymph and blood flow, as well as creating potential areas for impaired skin integrity.
Avoid blood pressure (BP) readings, venipuncture, intravenous (IV) lines, and vaccinations in affected arm. As indicated, advise patient to get a medical alert bracelet that cautions against these actions.	BP cuffs can constrict lymphatic pathways, and injections or blood draws will cause an opening in the skin, providing an entrance for bacteria.
Consult physical therapist (PT) and health care provider about development of an exercise plan.	Exercise increases mobility, which promotes lymphatic flow. This in turn helps decrease edema.
As indicated, suggest use of elastic bandages, compression garments, or sequential compression devices.	Elastic bandages decrease edema in mild, chronic cases of lymphedema. The other devices decrease edema in more severe cases of lymphedema.